A Global Perspective: Exploring the World of International Medical Education

After more than a decade on the air, ER still ranks as one of the most popular dramas in TV history. Not surprisingly, more than a few MDs have come to appreciate the intricate “medspeak,” highly realistic plots, and multidimensional characters like Dr. Carter, Dr. Kovac, Dr. Benton and Dr. Corday. But what can a TV show possibly tell us about the state of the American medical community and medical education? It might seem like a minor point at first, but one casting note is worth pointing out, if only for the symbolism: Many viewers will note that several U.S.-trained doctors have checked in and out of County General Hospital. Meanwhile Dr. Corday, the highly driven British surgeon, is still in residence and currently serving as the assistant chief of surgery. From that perspective, ER’s “MD makeover” symbolizes some interesting institutional developments in the American medical community: You could argue that Dr. Corday, an international medical graduate (IMG) who is passionately committed to her craft and her patients, represents what many believe is the future of the U.S. medical community. Increasingly, leading experts believe that a broad, international medical background is critical to the future well-being of the country’s patients, hospitals, and medical system.

From SARS, Bioterrorism, and AIDS to increased use of technology, rising healthcare cost/inequities, and doctor/nurse shortages, Medicine is being transformed as never before. The patient population today is vastly differentiated, diversified, and more empowered (via the Internet), signaling a new change in the patient-doctor relationship. Subsequently, there is an increased need for highly skilled doctors who embody the “global perspective” – a keen appreciation of the socio-economic/cultural factors that impact Medicine coupled with superior core skills and a talent for patient care – and not just the traditional and increasingly outdated view of medical practice. As a group, IMGs already fill some of the most critical positions in GP and specialty medicine. This is clearly a big shift from just thirty years ago. Back then, U.S. medical school applicants did not even consider international schools and IMGs were rarely considered for top residency posts. Today, thousands of American-born IMGs play a vital “vanguard” role in the U.S. medical community, and bring a critically important global perspective to medical practice. Subsequently, it is increasingly common for an American med student to enroll at a “foreign” (Caribbean, European, Australian) school, complete his or her clinicals in far-off locations, such as Prague, and return to practice in New York. So what is it that initiated this trend and why is it important for aspiring doctors to explore the world of international medical education? To answer this question fully, it’s important to look at the challenges transforming the American medical community, examine the evolution of medical education and provide some insight into the IMG experience.

Understanding the Challenges

In the United States, the medical community faces multiple challenges ranging from socio-economic factors to fundamental institutional changes. American doctors face an increasingly diversified patient population coupled with unique, demographic-based needs (minority/emigrant health), chronic health problems, high-risk behavior, environmental health hazards, increasing age/racial diversity of population and growing socio-economic disparities in healthcare. Most critically, predicted physician shortages are threatening to impede the very delivery of healthcare to some of the country’s most isolated constituencies: rural and urban communities. U.S. medical schools have been churning out 15,000 to 16,000 graduates, according to the Department of Health and Human Services, but census data show the population has increased 24 percent, from more than 226 million to more than 281 million people. While 972,000 physicians are projected for 2020, more than 1 million are needed. And a recent report by the Health Resources and Services Administration shows a current ratio of one worker for every 637 persons, a decrease from the 1970s’ ratio of 1:457. More critically, the number of physicians as a percentage of the student body in schools of public health plunged from 61 percent of all students in 1946 to 11 percent in 1979. The impending crisis might be considered catastrophic were it not for an emergent group of IMGs who are stepping into the void and filling a very critical need. In addition to filling the preexisting gaps in hospitals and clinics, IMGs also play a vital role in caring for – otherwise overlooked – racial/ethnic communities with very specific needs. In this respect, IMGs are integral to the future well-being of the nation’s patients and healthcare system. Not surprisingly, the AMA has focused its efforts on minimizing work delays for non-American IMGs, publicizing the need for enhanced minority representation, collaborating with public and private sectors to ensure adequate physician supply, among other measures. But before we examine the IMG experience directly, it is important to understand the system that is responsible for developing this new breed of doctor.

The Evolution of Medical Education

Given the physician glut and the preexisting challenges facing the U.S. medical community, especially socio-economic/cultural factors, many experts now advocate new strategies for capacity building. Some believe that a broad, international medical experience is vital if doctors are to meet these challenges effectively. It is against this background that international medical education (combining the best global learning practices) evolved outside the United States. As noted in a 2001 report titled Health Policies for the 21st Century: Challenges and Recommendations for the U.S. Department of Health and Human Services, the U.S. medical community has directed funds away from physician training and toward research, technology, and construction of healthcare facilities. Meanwhile, U.S.-based medical schools have continued to focus on technology and biomedical research. As a result, “[the] the major federal investments in capacity building for health have not systematically funded the public health infrastructure.”

Given this situation, perhaps it was inevitable that “foreign” medical schools would emerge to meet some of the challenges in American healthcare. In taking a training-focused approach to medical education and employing innovative curricula, many of these schools not only pioneer international medical education, but produce an entirely new breed of MDs who embody the global perspective and a uniquely “hybrid” view of Medicine. One school that has led the way is Grenada-based St. George’s University.

Founded in 1976 to anticipate global healthcare challenges, the University has since evolved from a Medical School to an international center of education, adding a School of Medicine and a School of Arts & Sciences. The University created the first truly global curriculum, drawing on the best of U.S. and U.K. medical systems. It is this tradition of commitment to academic leadership that has drawn Nobel Prize winners to St. George’s academic board, and professors and visiting scholars from the most prestigious institutions in the world, including Harvard University, London School of Hygiene and Tropical Health, and the Rockefeller Institute. In fact, the School of Medicine has a strong and stable faculty of 800 members, with full-time professors with an average tenure of ten years. It also has a network of prestigious clinical training affiliations with well-established U.S. and U.K. institutions.

With more than 5,000 graduates practicing – in different specialties and sub-specialties – worldwide, St. George’s has developed a well-earned reputation for excellence in the lecture hall, as well as in the operating room. Students score on parity with U.S. counterparts on standardized examinations and sometimes even exceed them, as they did in 2001. American observers like Dr. Daniel Ricciardi, Director of Medical Education at Long Island College Hospital, Brooklyn, NY, are quick to acknowledge that IMGs from schools like St. George’s are necessary for the well-being of an American medical community that is over-reliant on technology.

“In most instances throughout the U.S., [doctors] don’t really touch a patient anymore. [Basically], we’ve lost the compassion,” said Dr. Ricciardi. “But the beauty of St. George’s University is that it gives [medical students] a little bit more of an insight into the compassion.”

The IMG Experience

Currently, there are thousands of IMGs practicing across the United States, and the numbers are set to increase, especially as students begin to consider all of their options. Nearly 25 percent of physicians in U.S. allopathic training programs in 2002-2003 were IMGs, and the percentage of DOs continues to increase to meet specific needs (source: AMA). For example, the rising number of residents conversant in Spanish readily meets the needs of this fast-growing minority group. Of course, the day-to-day experience is no different from their U.S.-educated counterparts. In fact, many are trailblazing a path for others to follow. One remarkable example is that of Dr. Reginald Abraham. A 1990 graduate of St. George’s University, Dr. Abraham exemplifies the University’s international heritage and commitment to a broad medical education.

A Sri Lankan born in Malaysia and schooled in Canada, Dr. Abraham had always been a world traveler. So when it came time for him to pursue a career in medicine, St. George’s University was the perfect fit. The diverse community, global perspective on medicine, and world of opportunities inspired him to take the international experience even further. For Dr. Abraham, that meant clinical rotations in England and New York, a surgical residency at Yale University, and a Fellowship in Cardiothoracic Surgery at New York Medical College. Now a specialist in minimally invasive heart surgery and off-pump coronary artery surgery, he is one of California’s top surgeons, a strong advocate of St. George’s unique medical training regimen, and uniquely attuned to the new challenges facing the American medical community.

“The world, and the medical world in particular, have changed dramatically,” noted Dr. Abraham. “Increasingly, people of different cultures are making America their new home. So it’s vitally important that American doctors have the knowledge base and the adaptability needed to appreciate different cultural nuances, as well as relate to people of different cultures. The more broad-based an education you have, the more capable a physician you’ll become.”

Abraham, who credits St. George’s with providing him with “a very cosmopolitan and enriching experience,” proves just how important it is for American-based MDs to possess that increasingly key advantage: an international background. Of course, this is not restricted to the United States alone. Many of Abraham’s classmates represent the promise outlined in St. George’s “Think Beyond” tagline. The emphasis on “learn here, practice anywhere” has enabled thousands of doctors practicing outside the U.S. to achieve an equal level of professional excellence and personal fulfillment. One notable example is Dr. Angela Huang, a Taiwanese doctor currently practicing in her homeland. After moving to the United States, she went on to pursue her undergraduate degree in biochemistry from the University of Minnesota. She sought out St. George’s because it made for the best fit … but she also benefited from the broad and diverse educational experience. For example, while most students choose to do their clinical training in the U.S., she chose to do her rotations in England, where she had the chance to experience yet another culture. After graduation from St. George’s, Dr. Huang decided to return to Taiwan, where she completed her residency in internal medicine at Cheng-Hsin Rehabilitation Center and went on to pursue a pulmonary medicine fellowship.

A Global Perspective

There has never been a more critical time in the history of the U.S. medical community, and healthcare reform – the primary catalyst for change (above and beyond education) – is once again a key subject in this year’s presidential elections. With new challenges transforming the very institution of Medicine, hospitals and patients alike need doctors who understand and anticipate their unique needs. Experts now tout the increasingly important balance between excellent healthcare delivery and cultural awareness in the patient-doctor relationship, noting the singular importance of “foreign” medical schools like St. George’s University. For prospective MDs, the bottom line is this: While ER’s Dr. Corday represents the new image of the IMG on-screen, real-world practitioners like Dr. Abraham bring a new level of excellence, expertise, and leadership to the U.S. medical community, inspiring many more to follow in their globe-trotting footsteps.

Published on 08/11/2004

Conservation Medicine

Dr. Alonso Aguirre, Executive Director of Conservation Medicine with the Wildlife Trust, will conduct a seminar at St. George’s on Monday, April 5 at 5pm in the Bourne Hall. Dr. Aguirre is one of the founders of Conservation Medicine – an emerging medical discipline that joins the expertise of veterinary medicine and human medicine in the service of ecosystem health. At a time of damaged and collapsing habitats around the world where biodiversity loss now threatens the ecological infrastructure of human populations, conservation medicine offers considerable global relevancy. In the truest medical tradition, this discipline seeks to diagnose the proximate and ultimate causes of health decline at the ecosystem level and to implement corrective policies that will reclaim and safeguard the variety of environments supporting human and animal life. This exciting new medical specialty promises to expand the capabilities of both physicians and veterinarians in addressing increasingly pressing environmental and societal concerns in virtually every part of the world today.

Published on 04/05/2004

Kingstown Medical College Celebrates 25 Years of Academic Excellence

The Kingstown Medical College, a long time affiliate of St. George’s University School of Medicine, kicked off a week long celebration of its 25th Anniversary on February 14th 2004. The Kingstown Medical College was founded in January, 1979 and since its inception, has provided outstanding preclinical training for St. George’s University medical students during their fifth and sixth term.

SGU’s medical students spend a critical period of their medical training at KMC in a semester whose curriculum bridges knowledge from the basic sciences to the clinical program. Their program includes frequent visits to the Milton Cato Memorial Hospital where students obtain clinical experience in core rotations and certain specialties.

KMC’s 25th Anniversary celebration was launched by a Cardiology Symposium chaired by His Excellency, Sir Frederick N. Ballantyne, followed by a luncheon reception attended by faculty, staff, alumni, and distinguished guests of Kingstown Medical College and St. George’s University. A Celebratory Program in the KMC Lecture Hall was moderated by the Dean of KMC, Dr. Ed Johnson, who introduced the principle speakers.

The keynote speakers, Drs. Mary Jeanne Kreek and Richard Roberts, both of the Cornell and Rockefeller Universities, have been long time lecturers at KMC. Dr. Frederick Ballantyne, Governor General of St. Vincent and one of the School’s first champions back in 1978 and Dr. Charles R Modica, Chancellor of St. George’s University, gave somewhat different, but equally entertaining early histories of KMC. Rosalind Ambrose, MD (SGU, 1983) Director of Medical Education at the Milton Cato Memorial Hospital, spoke of her experiences as an early student at the University. In addition, Dr. Douglas Slater, Minister of Health and the Environment SVG; The Honorable Vincent Beache, Acting Prime Minister for SVG., also spoke at the Celebratory Program. Eloquent closing remarks were offered by Dr. Jack Cush, SGU graduate and Chair of the Academic Board and member of the Board of Trustees.

The celebration culminated in an evening reception, hosted by Sir Fredrick and Lady Sally Ann Ballantyne, at Government House. Toasts were offered by Sir Frederick, Chancellor Modica, and Dean Johnson. The successes of KMC and SGU graduates was noted and special tribute was paid to the 21 Vincentian graduates who are now practicing in Saint Vincent, many of whom serve as Clinical Faculty at the Milton Cato Memorial Hospital.

Additional events during the “Celebration Week” included a “Handing over of the Keys” ceremony on Tuesday the 17th. The keys were presented in recognition of the renovations performed on the Calliaqua Clinic by KMC staff members. The Clinic, a training site for KMC in the early 1980’s, was remodeled to provide better patient care and to again provide a clinical training site for KMC’s students. On Thursday, February 19th, Dr. Timothy Providence, the Director of the Cato Memorial Hospital and Dr. Frederick Ballantyne, the Governor General, officially thanked SGU and KMC for the donation of 5 Automated External Defibrillators, which were obtained through the dedicated efforts of Rosann Hansford, RN, Deputy Director, Cardiology Unit of University Health Services at SGU and Dr. Henry Halperin, ACLS visiting instructor from John’s Hopkins University.

The week’s activities closed with a dinner party for the employees of KMC on Saturday evening February 21st. On this occasion employees with 10 or more years service at KMC were awarded a certificate of appreciation and given gifts to note their contribution, with a special acknowledgement of those with 25 years of service. The Administration, faculty and staff of KMC extended their sincere appreciation to all of the members of the Vincentian Government and community, SGU graduates and Grenada visitors who participated in these festivities.

Published on 02/27/2004

Surgeon Titles: Dr. vs. Mr.

As Originally Published in The eZine “Education Update

While surgeons carry the appellation “Dr.” in the USA and other parts of the world, in the UK they are referred to as “Mr.” How has this anomaly arisen? Academically, in order to be called “Dr.” one must hold a doctoral degree (the highest academic degree in any field of knowledge), such as Doctor of Medicine, M.D., or Doctor of any other discipline. In the USA, an M.D. is a licensing qualification to practice medicine, whereas in Britain, an M.D. is a postgraduate thesis degree. In order to practice medicine in Britain, students must attain a Bachelor of Medicine and a Bachelor of Surgery degree (MB and BS). Therefore they are not, in the strictest sense, “doctors.” However, once graduated in Britain, all graduates are referred to as Doctor, as are consultant and trainee physicians and other specialists––all except surgeons.

The word “doctor” is derived from the Latin doctor-oris, meaning teacher or instructor, and in Middle English (c. 1150-1500) it became used for any learned man or medical practitioner. The title “Mr.” is a 16th century English variant of Master, derived from the Latin Magister, which means master or teacher. Following the fall of the Roman Empire, most surgery in Europe was performed in monasteries by monks and their assistants, the barbers. As well as cutting hair and shaving, barbers helped with blood-letting.

The Medieval Universities were founded to teach subjects, including medicine, which had no place in the ecclesiastical curriculum. Salerno was one of the first medical schools and was established by the middle of the 11th century. Courses were initially available to physicians and surgeons, but not to apothecaries.

In 1123 CE, Pope Calistas II decreed that monks must not shed blood, and it was this ruling that resulted in the teaching of surgeons being forbidden in church-dominated universities. Surgeons, therefore, served an apprenticeship, whilst physicians spent four years at university, leading to a Bachelor of Medicine degree and a possible further thesis leading to a Doctorate. The Pope’s ruling also resulted in a great boost to the barbers, who now performed dental extractions and fracture treatments as well as blood-letting. Because of their increased role, they became known as the barber-surgeons, and monks then administered only to the spiritual needs of patients.

At this time, true surgeons also developed. They were more skilled than the barber-surgeons, but were apprenticed and not university trained, and therefore could not style themselves as “doctors.”

In 1493 English surgeons decided to enter a working agreement with the barber-surgeons, and this association was given Royal assent in 1540 when Henry VIII, by Act of Parliament, united the two groups under the name of “Masters, Governors of the Mystery and Commonalty of Barbers and Surgery of London.” From this time, by Royal edict the barbers could only perform barbery and extraction of teeth, and the surgeons had to refrain from cutting hair and shaving people! King Henry VIII gave each member of this newly formed group the right to be addressed as “Master,” and in time “Master” was pronounced “Mr.” So when a British Surgeon is addressed as “Mr.” he is actually being honoured, as in reality he is being called “Master.” Female surgeons are called Miss, Ms. or Mrs.

The association of surgeons and barber-surgeons lasted until 1745, when the surgeons petitioned the English parliament for a separation that lasts to this day. The barber-surgeons are now represented by the Benevolent Barbers’ City Livery Company.

By Mr. Rodney Croft

Published on 01/05/2004